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A systematic review of the effectiveness of the Safewards Model and an empirical study of the relationships between adverse childhood experiences, attachment, resilience, psychological distress and trauma in forensic mental health populations

Finch, Katie 2020. A systematic review of the effectiveness of the Safewards Model and an empirical study of the relationships between adverse childhood experiences, attachment, resilience, psychological distress and trauma in forensic mental health populations. ClinPsy Thesis, Cardiff University.
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This thesis is formed of two papers; a systematic review and an empirical study. The systematic review aimed to explore the effectiveness of the Safewards Model, which intends to reduce levels of conflict (such as violence and aggression) and containment (e.g. restraint or seclusion) in psychiatric inpatient settings through the use of ten interventions. The interventions are designed to enhance the ways in which staff actions can reduce the likelihood of conflict events (and subsequent containment) occurring. Conflict and containment have a range of negative outcomes for both staff and service users, however Safewards has shown promise in reducing the incidence of these events, is implemented widely and recommended in best-practice guidelines. Despite this, a review of its effectiveness is lacking. The systematic review aimed to evaluate the effectiveness of Safewards with regards to reduction in conflict and containment and other key outcomes. Searches were conducted using databases Psych Info, PubMed, Web of Science and Cochrane library, alongside additional generic searches, citation searches and reviewing reference lists. Articles were screened independently by two reviewers and quality assessed. Twelve studies were included; only one was a randomised control trial with the remaining studies utilising quasi-experimental designs, non-randomised with control design, cross-sectional designs and repeated measures designs. All but one of the studies implemented all ten interventions. The results of the study demonstrated that Safewards generally has a positive effect and can help reduce conflict and containment in ward settings. The quality of literature however remains inadequate in order to ascertain effectiveness conclusively. The review synthesises the current evidence-base for the Safewards model and highlights its clinical potential, nonetheless recommendations for more robust research in future are made in order to establish more conclusive evidence. The empirical paper is a quantitative study that aimed to explore predictive relationships between adverse childhood experiences (ACEs), attachment style and resilience with psychological distress and trauma in forensic mental health populations. Previous research has found an association between ACEs and attachment style with later life psychological distress, with further studies reporting a mediating effect of attachment on this association. Additionally, it has also been demonstrated that psychiatric inpatients and prison populations often experience greater number of ACEs and higher levels of poor mental health. Despite this, little research has examined these associations within a forensic mental health subpopulation; individuals often presenting with histories of offending and acute, chronic mental health difficulties. The study originally aimed to only recruit a current forensic mental health inpatient sample, however the COVID19 pandemic limited the ability to do so, causing a substantial delay to ethics approval, alongside lower staff levels, lack of staff presence on the wards and restricted access to visitors. As a result, recruitment was amended to be conducted remotely and participants were also sought online utilising website, allowing individuals in the community who had both forensic histories and mental health diagnoses to participate. A total of 128 participants were recruited to complete six digitised questionnaires measuring ACEs, attachment, child and adult resilience, psychological distress and trauma. Statistical analysis of the data showed that ACEs, attachment style and adult resilience were the most significant predictors of psychological distress and trauma. This meant individuals with higher numbers of ACEs and insecure attachment style were significantly more likely to experience greater levels of distress. Higher ACEs and insecure attachment also increased the likelihood of reaching diagnostic threshold for both post-traumatic stress disorder (PTSD) and complex posttraumatic stress disorder (CPTSD). Greater adult resilience meanwhile significantly predicted lower rates of psychological distress, and individuals with higher adult resilience scores were less likely to reach the diagnostic threshold for PTSD and CPTSD. Attachment was also found to mediate the relationship between ACEs and psychological distress and trauma, suggesting greater ACEs may result in insecure attachment which then leads to greater levels of psychological distress. A striking finding of the study was that 95% of the sample had experienced high levels of childhood adversity (defined as four or more ACEs) compared to rates in the general population. Given such results, one main conclusion of the study was that considering childhood adversity is essential within clinical practice and forensic mental health settings specifically. It was also concluded that in order to support individuals in the most effective and appropriate way, factors such as sources of resilience and ability to form and maintain meaningful relationships should be considered and incorporated into existing practice. The study adds to the growing literature surrounding trauma-informed care, in that approaches such as this may be beneficial in forensic mental health settings in reducing the potential lifelong impact of childhood adversity.

Item Type: Thesis (DClinPsy)
Date Type: Completion
Status: Unpublished
Schools: Psychology
Subjects: B Philosophy. Psychology. Religion > BF Psychology
Date of First Compliant Deposit: 14 October 2020
Last Modified: 13 Oct 2021 01:30

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